Originally developed and empirically supported as an outpatient treatment for borderline personality disorder (BPD) (Linehan, 1993a, 1993b; Linehan et al., 1991), dialectical behavior therapy (DBT) recently has been adapted for adults with BPD and comorbid substance use disorders (SUDs) (Linehan et al., 2002, 1999). This modified treatment, DBT-SUD, has shown promise in two small randomized controlled trials and is currently being tested in a two-site study (University of Washington and Duke University Medical Center) funded by the National Institute of Drug Abuse (NIDA). The purpose of this paper is to provide a primer on the basics of DBT-SUD. For more comprehensive descriptions of DBT-SUD, the interested reader is referred to the treatment manual (Linehan 1993b), treatment outcome studies (Linehan et al., 2002, 1999), online resources for DBT-SUD training <www.behavioraltech.org> or book chapters on DBT-SUD (Rosenthal et al., 2005).
Dialectical behavior therapy for adults with BPD and comorbid SUDs was developed, in part, out of recognition that individuals with BPD often have problems with substance abuse, and that up to two-thirds of those diagnosed with SUD also meet diagnostic criteria for BPD (Dulit et al., 1990). In addition, there may be common etiological and maintaining factors across BPD and SUD, such as difficulties with the regulation of emotional experience and expression, as well as impulsivity (Bornovalova et al., 2005; Trull et al., 2001). Clinicians are faced with an enormous challenge when treating individuals with co-occurring BPD and SUD. Compared to those with BPD only, those with BPD and SUDs may show more severe psychopathology, including greater anxiety and suicide attempts (van den Bosch et al., 2001). It is unclear whether standard drug counseling approaches common in the substance abuse treatment community (e.g., 12-step) are efficacious for these difficult-to-treat patients. However, guidelines for implementing treatments for dually diagnosed patients have been articulated (Drake et al., 2001), and such treatments have been developed for individuals with both SUD and schizophrenia, antisocial personality disorder, and a history of interpersonal victimization, for example (Barrowclough et al., 2001; Drake et al., 1993; Messina et al., 1999; Najavits et al., 1998). In line with the hypothesis that a specifically tailored treatment may be appropriate for this population, and following NIDA guidelines for psychosocial treatment development, Linehan and colleagues developed DBT-SUD (unpublished data).
Like standard DBT, the modified version of this outpatient treatment is a blend of change (e.g., behavior therapy) and acceptance (e.g., mindfulness training) approaches woven together by a set of philosophical assumptions, a biosocial theory and multiple modes of treatment (e.g., individual therapy, group skills training, pharmacotherapy). On the one hand, as a behavioral treatment, DBT-SUD relentlessly pursues changing a range of maladaptive behaviors using standard behavioral principles and procedures (e.g., contingency management, shaping, stimulus control). On the other hand, as an acceptance-based treatment, DBT-SUD provides an unwavering emphasis on patient validation, mindfulness skills, and an underlying assumption, that, in some moments of life, efforts to change what inherently cannot be changed may exacerbate problems, rather than solve them.
Instead of monochromatically being change- or acceptance-focused, the DBT-SUD therapist carefully integrates both behavioral change and acceptance throughout all aspects of treatment. Indeed, the ubiquitous dialectic in DBT is that of acceptance and change. Neither one alone is thought to be sufficient for all problems. Instead, the DBT-SUD therapist constantly is searching for ways to help any given problem using either, or both, change and acceptance strategies. The pragmatic goal is to identify and implement an optimal solution to each problem that arises in a fluid context, while being completely willing to let go of any solution, as needed, in response to new problems or evidence that any one solution does not appear to be helpful. A balance between acceptance and change is important, but this does not always translate literally into an equal distribution of acceptance and change. Like a skilled athlete adjusting to the weather conditions during a game, the relative proportion of acceptance and change is a function of what appears useful in any given moment.Empirical Support
Two randomized trials examining DBT-SUD have been conducted. In the first study, 28 women diagnosed with BPD and/or SUD were randomly assigned to receive one year of DBT-SUD or treatment as usual (TAU) in the community (Linehan et al., 1999). After treatment, patients receiving DBT-SUD attended significantly more individual psychotherapy sessions, dropped out of treatment less often and had significantly less substance use, as measured via structured interviews and urinary analyses. At 16-month follow-up, patients receiving DBT-SUD reported higher global and social adjustment compared to those receiving TAU.
In the second study, 23 adults with BPD and opioid dependence (all heroin) were randomly assigned to receive either one year of DBT-SUD or a comprehensive treatment that included 12-step meetings (e.g., Narcotics Anonymous/Alcoholics Anonymous) plus individual therapy sessions using a manualized approach based purely in acceptance without direct emphasis on behavioral change (comprehensive validation therapy) (Linehan et al., 2002). All patients concurrently received levomethadyl (Orlaam) as an opiate replacement medication. Patients in both treatment conditions evidenced decreases in drug use and improvements in social and general adjustment following treatment. However, in the last four months of treatment, patients receiving DBT-SUD continued to maintain previous treatment gains, whereas those receiving comprehensive validation had an increase in opiate use. Although a larger follow-up study currently is being conducted to replicate and extend these findings, these preliminary studies taken together suggest that DBT-SUD holds promise as a treatment for substance users with BPD.